Download patient medical history - Linda Woodson Dermatology

PATIENT MEDICAL HISTORY
PATIENT: _______________________________________________________________ DATE: ____/____/____
MEDICATION ALLERGIES: p NONE p YES (PLEASE LIST)______________________________________
______________________________________________________________________________________________
Are you sensitive to: p Foods p Environment (dust/pollen/pets) p Bandages p Topical Neosporin
Have you ever had "Numbing Medicine" (Novacaine, Lidocaine)? p No p Yes
Any Reaction? p No p Yes
Current Medications (including over-the-counter remedies, vitamins, herbals) 1)________________________________
2) _________________________________ 3) ______________________________ 4) ______________________________
5) _________________________________ 6) ______________________________ 7) ______________________________
Are you required to take antibiotics prior to dental or surgical procedures? p No p Yes
Do you have or have you ever had the following Conditions? Denote a family condition checking where indicated:
LUNGS:
NO
YES
FAMILY HISTORY
OTHER SYSTEMIC:
Bronchitis
Diabetes
Emphysema
Asthma
Chronic Cough
Morning Cough
Shortness of Breath
Thyroid
Kidney
Dialysis
Excessive Urination
Burning while Urinating
Wheezing
Allergies
CARDIOVASCULAR:
Gastrointestinal
Nausea, vomiting
Diarrhea
Arthritis
High Blood Pressure
Chest Pain
Convulsions/Seizures
Fainting
Heart Attack
Polycystic ovaries
Heart Murmur
Irregular heartbeat
Yeast Infections
INFECTIOUS DISEASE:
Phlebitis
Blood clots
Hepatitis
HIV
Pacemaker
MRSA
HEMATOLOGY
ONCOLOGY:
Syphilis
NO
YES
FAMILY HISTORY
Bleeding disorders
Cancer
if yes, what type of cancer _____________________________________________
SKIN: Have you ever had Skin Cancer? p No p Yes What type? _______________________________________
Has anyone in your family had Skin Cancer? p No p Yes What type? _______________________________
Do you have a history of any specific skin diseases? p No p Yes What type? ___________________________
Do you have problems with wounds healing? p No p Yes
Do you develop large scars (Keloids) after surgery? p No p Yes
List any other diseases or conditions:______________________________________________________________
List any Surgical Procedures in the last six months __________________________________________________
(Women) Are you currently pregnant? p No p Yes Due date? ___________________________________
SOCIAL HISTORY:
Do you drink alcohol? p No p Yes How many drinks per day? __________________________________
Do you use recreational drugs? p No p Yes What kind? ___________________ How often? ____________
Do you smoke? p No p Yes How often? ___________________ How much? _________________________
What is your occupation? _______________________________________ Hobbies? _____________________
Completed by p Patient p Parent/Guardian p Medical Assistant _____________ (initials)
___________________________________________________
Patient
Date
________________________________________
Provider
Date